Perspective
published: 27 February 2017
Edited by:
Esther-Lee Marcus,
Herzog Hospital, Israel
Reviewed by:
Grazia Daniela Femminella,
University of Naples Federico II, Italy
Mario Ulises Pérez-Zepeda,
Instituto Nacional de Geriatría,
Mexico
*Correspondence:
Gary Sinoff
gsinoff@gmail.com
Specialty section:
This article was submitted
to Geriatric Medicine,
a section of the journal
Frontiers in Medicine
Received: 02 December 2016
Accepted: 01 February 2017
Published: 27 February 2017
Citation:
Sinoff G (2017) Thanatophobia
(Death Anxiety) in the Elderly: The
Problem of the Child’s Inability to
Assess Their Own Parent’s Death
Anxiety State.
Front. Med. 4:11.
doi: 10.3389/fmed.2017.00011
Frontiers in Medicine  |  www.frontiersin.org
doi: 10.3389/fmed.2017.00011
Thanatophobia (Death Anxiety) in the
Elderly: The Problem of the Child’s
Inability to Assess Their Own Parent’s
Death Anxiety State
Gary Sinoff*
Faculty of Social Welfare and Health Sciences, Department of Gerontology, University of Haifa, Haifa, Israel
Thanatophobia is omnipresent in our lives. Research has shown separate but connected
constructs: fear of death or fear of the dying process. The influences on death anxiety
are varied including religiosity, gender, psychological state, and age. It is often assumed
by the children of the elderly that the fear of death is prevalent in their parents. Daily the
medical staff encounters the presence of death anxiety: from family members or the staff
itself. In order to understand this phenomenon, a three-tier study was conducted on
non-terminal elderly inpatients in an acute geriatric care ward. The study showed that the
elderly had low levels of anxiety (scoring 4/15 on Templer’s Death Anxiety Scale) but their
children scored higher for themselves (6.9/15) and for their parents (8.9/15). A regression
model showed that only the presence of generalized anxiety and religiosity of parent had
an effect explaining 33.6% of the variance. Death anxiety of death is usually absent in
the elderly but rather they fear the dying process. On the other hand, their children do
fear death, which they extrapolate onto their parents. This causes conflicts since the
children prevent disclosure of relevant medical information to their parents. This has to
be addressed by the staff when dealing with family members, to allow open and honest
communication with their patients. The staff need to explain to the family that the elderly
are not afraid of death but of the suffering from the dying process.
Keywords: thanatophobia, elderly patients, death anxiety, anxiety, elderly
INTRODUCTION
Death anxiety is present in our lives and affects each and every one of us in different ways. This
phobia has been described as a feeling of dread, anxiety or fear at the thought of death, or anything
to do with dying (1). This anxiety related to fear of death was termed thanatophobia by Sigmund
Freund in 1915 in his seminal essays titled: Thoughts for the Time on War and Death. Freud
believed it to be related to one’s unconscious belief in one’s own immortality. Jung in 1933 wrote
that “Life is like a parable, starts at birth and ends at death. In other words, death is part of the
life-cycle.” So understanding the inevitability of dying is essential to our living.
Over the years, research has shown two separate but connected constructs of death anxiety: fear
of death or fear of the dying process (2). Until this day, the argument remains. Is one conceptually
talking about fear of death or fear of the dying process? Death anxiety has been characterized as
a conscious fear of death, a fear for the body after death, a fear of lost time, a fear of suffering, a
fear of the unknown, and a fear of loneliness (3–5). In fact, Farley (6) stated that it is: “A feeling of
1 February 2017 | Volume 4 | Article 11
Sinoff
dread, apprehension or solicitude (anxiety) when one thinks of
the process of dying, or ceasing to ‘be’.”
What actually affects the presence of death anxiety is still
debatable. Many variables have been proposed to influence death
anxiety amongst them religiosity, gender, psychological state and
age. The psychological state is a known factor to cause higher
death anxiety, especially in persons suffering from generalized
anxiety disorder (7, 8). It has been stated that death anxiety is
probably a consequence of unresolved psychological and physi-
cal distress. Kesebir (9) showed that those with higher level of
humility, that is less feeling of self-importance, actually had lower
levels of death anxiety. On another note, McCarthy (10) felt that
death anxiety in adults was a consequence of the struggle to psy-
chologically separate from their parents and requiring to form an
independent and individual identity. From this viewpoint, adult
children struggle to psychologically separate from their parents
often resulting in anxiety for death of their parent.
The protective effect of religiosity is in dispute (11, 12). In the
literature, there have been reports that religiosity has a positive
protective effect since one is going to meet the Supreme Being
and finally be given their rewards for their life on Earth (13–15).
Yet others have found it to increase the fear of death for the same
reason that they will be judged in heaven for their deeds while
they were on Earth, a problem cross-culturally (16–19).
Gender has also been in discussion since some reports have
found greater prevalence of death anxiety in males (20), and oth-
ers describe greater death anxiety in females (21, 22). So it is still
unclear if gender constitutes a protective or harmful effect.
Regarding age there have been multiple reports. One is aware
that the aging process entails more than just changes in one’s
appearance, cognitive decline, or increased generalized aches
and pains; but also knowing that one is moving inevitably closer
to death (23). The presence of death anxiety is reported to peak
in middle age and disappear in the elderly (20, 24, 25). Russac
and colleagues (26) also found that death anxiety was high in the
young adult population (20-year olds) in both sexes and then
declined over time but spiked once again at 50, particularly in
the female population. However, they were unable to explain this
phenomenon. The fact that the level of death anxiety is age related
is an important finding for the multidisciplinary staff of a geriatric
health team.
The staff in a geriatric care setting encounters on a daily basis
the presence of death anxiety, whether from the side of the patient
and/or their family member, or from the staff itself caring with
persons with life-threatening diseases.
Life experiences with death may also influence attitudes about
death and dying and contribute to the levels of death anxiety. It
has been argued that from the staff point of view, the relating to
death may be a culturally based effect. Sharif Nia and colleagues
(27) recently reviewed the problem of death anxiety amongst
nursing staff and provided information that culture has a major
effect on how nurses adapt to death. One study showed that
amongst Egyptian nursing students, the level of death anxiety
was higher than Spanish nursing students but this was explained
partially in the difference in age and experience (28), a similar
finding was also in a study done in America (29). The presence
of high levels of death anxiety often resulted, cross-culturally,
Frontiers in Medicine  |  www.frontiersin.org
Thanatophobia (Death Anxiety) in the Elderly
in staff avoiding providing care for dying patients whether from
Israel (30), Iran (31), or Japan (32).
The very existence of death anxiety often delays the ability
to make unbiased and uninfluenced decisions on the side of the
patient, family, or the medical staff. This becomes particularly
problematic nowadays with the intimate involvement of the mid-
dle-aged children of the elderly in the decision making process
for their elderly parent. Possibly the child’s belief in the existence
of death anxiety on the part of their parents may impede the flow
of information, sometimes against the patient’s own rights.
Studies have examined death anxiety in the young and
elderly separately, but few have related to children’s ability to
proxy-assess death anxiety in their own parents. A three-tier
study was done by the author and colleagues to answer this
complex story (33). Initially, the level of death anxiety in the
young and old was investigated. Then, whether the problem is
fear of death or fear of dying process in both age groups was
examined, and finally was studied whether the middle-aged
children of elderly patients were able to assess correctly, by
proxy, the level of death anxiety in their own parents. The work-
ing hypotheses were that the level of death anxiety would be
higher in the children than the elderly, the elderly would have
more fear of the dying process than actual death and finally that
children would not be able to proxy-assess correctly their own
parent’s death anxiety level.
In the study, 44 elderly children couplets were examined, and
it was found that the elderly scored lower on Templer’s Death
Anxiety Scale (DAS) (mean 4.0/15) compared to children scoring
for themselves (mean 6.9/15; P-value < 0.01). Interestingly, chil-
dren scored their own parents even higher on proxy assessment
(mean 8.1/15; P-value < 0.001 comparing to the actual score of
the elderly). All of the elderly stated that they were afraid of dying
a painful death, that is the dying process, and this was also picked
up their children. However, the children felt that their parents
were afraid of death or dying and were worrying about this all the
time. Accordingly, the children assumed that their parents were
afraid to see death before them or that their parent felt that their
future was bleak. In fact this is opposite to what the elderly actu-
ally report. However, these beliefs correlated with the children’s
own fear of death and dying (Table 1). A multiple linear regres-
sion with score on proxy-assessment DAS scare as the dependent
variable and age, religiosity, presence of generalized anxiety and
depression elderly, gender, education level, holocaust survivor,
level of cognitive problems and functional status of parent, and
age and religiosity of child were the independent variables. Only
the presence of generalized anxiety and religiosity of parent was
able to explain 33.6% of the variance.
As mentioned above, the presence or belief of the presence of
death anxiety may affect the ability to communicate with patients
about death as they age. To understand if this was gender related,
an analysis was performed, and it was shown that for both sexes
those who agreed to disclose medical problems to their parents
compared to non-disclosures, scored lower for their parents on
proxy assessment (males 4.7/15 versus 8.4/15 and females 9.6/15
versus 10.1/15). Most of the females agreed on disclosure (52.2%)
even though they scored their parents higher on proxy assess-
ment. Interestingly with regard to gender, males who believed in
2 February 2017 | Volume 4 | Article 11
Sinoff
Table 1 | Differences on Death Anxiety Scale: parent, child, and child proxy-assessing parent.
Question Parent (%)
1. I am very much afraid of dying 14
2. The thought of death often enters my mind 39
3. It makes me nervous when people talk about death 23
4. I dread to think about having an operation 34
5. I am afraid of death 11
6. I am afraid of getting cancer 36
7. The thought of death bothers me 11
8. I am often distressed by the way time flies so very rapidly 30
9. I fear dying a painful death 100
10. The subject of life after death troubles me greatly 5 7
11. I am really scared of having heart attack 39
12. I often think about how short life really is 36
13. I shudder when I hear people talk about World War III 14
14. The sight of a dead body is horrifying to me 7 41**
15. I feel that the future holds nothing for me to fear 41
*P < 0.05.
**P < 0.01.
***P < 0.001.
non-disclosure tended to mainly prevent flow of information to
their fathers (83%) and females to their mothers (56%).
In an attempt to explain this model of discrepancy, a multi-
ple linear regression with child-assessing parent DAS score as
dependent variable was performed. The only variable that was
significant was the presence of generalized anxiety disorder, which
the children picked up as death anxiety (t = 2.829, P < 0.01). All
the other independent variables such as age, gender, religiosity,
educational level, presence of depression, and cognitive decline,
had no effect on the model.
DISCUSSION
Death anxiety is a universal and fundamental phenomenon,
which affects humans to various degrees. Klein in 1948 described
that actually death anxiety is one of the basic feelings of humanity
and is the root to all anxiety. Humans are the only species who
are aware of the limitations to life and impending death. Kübhler-
Ross in her book On Death and Dying in 1969 (34) stated that
the problem of death anxiety is more a fear of death and psycho-
logical adjustment with the dying process. She emphasized five
different stages a person with end-of-life illness undergoes: denial
that death is eminent, anger and resentment that others will live,
bargaining to cope with death, depression when recognizing the
inevitability of death and finally acceptance.
Death anxiety has been identified to have six different attrib-
utes to the concept: emotion related to fear of disappearance,
cognitive acceptance of death, experiential that death anxiety is
not part of one’s conscious experience, development stage with
identity crises affecting the degree of death anxiety, sociocultural
shaping such as western societies concealing the sick and elderly
accompanied by denial of death and source motivation affecting
psychological status of the individual (1).
In addition there is a need to understand whether the prob-
lem of death anxiety is anxiety about death or anxiety about the
process of dying. The difference is clearly shown in two different
statements: “I fear death” and “I am afraid to die” (21).
Frontiers in Medicine  |  www.frontiersin.org 3 February 2017 | Volume 4 | Article 11
Thanatophobia (Death Anxiety) in the Elderly
Child (%) Child proxy-assessing parent (%)
48*** 46***
70** 50
42 50*
46 80***
61*** 61***
55 59
70*** 75***
54 48
84* 98
14
43 59
50 55
35* 46**
52***
57 68*
One role of increasing importance to the lives of adults in the
U.S. is that of caregiving for an elderly relative. Tomer and Eliason
(35) postulated that death anxiety is directly influenced by death
attitudes, past- and future-related regrets and is indirectly influ-
enced by coping processes, beliefs about one’s self and the world,
and by the degree to which death heighten one’s own awareness
of eventual death.
The hypothesis that death anxiety is higher in the young
compared to the elderly was proven by the difference on the DAS
mean scores in the above mentioned study (6.9 for children versus
4.0 for parents), a finding similar to reports in the literature (20,
24, 25). The literature reports that death anxiety peaks in middle
age and decreases with increasing age, a finding supported by
the author’s study. The stages of death anxiety may be summa-
rized as follows. About age 9–10, we realize that death is final;
in adolescence, we have this ingrained belief of invulnerability
and immortality. Changes occur in early adulthood when one
becomes a parent. By middle age, one is exposed to the finality
of life with death of parents, friends, and siblings. This being
the period of highest death anxiety. Finally in old age, the level
of death anxiety drops even in the face of death of spouses and
peers. Given that older adults are temporally closer to death and
probably encounter more frequent reminders of their mortality
than their younger counterparts, it may be that they have come
to some level of acceptance of this inevitable reality, at least at a
conscious level (23). Nevertheless, a future study needs to include
grandchildren for investigating death anxiety over lifespan.
The hypothesis that parents are not afraid of death but of
the dying process was supported in our study. This finding was
reported by others that elderly are more worried about the death
process, not of death (36). The dying process is more relevant
to the parent than the actual thought of death (all were worried
of dying with discomfort), and here the children were able to
correctly assess their parent’s fears. The final hypothesis that the
children incorrectly assess death anxiety of their own parents was
verified by difference in mean DAS scores (4.0 for parent versus
8.1 for child-assessing parent, P < 0.001).
Sinoff
From findings in the child’s self-assessment compared to
child-assessing parent, it was seen that the child tends to extrapo-
late their own beliefs onto their parents. The regression model
showed that the child is able to pick up some anxious traits, but
transliterated by the child into existence of death anxiety in his
parent. These may explain the child’s difficulty in permitting flow
of information to the parent (only 43% agreeing), in contradiction
to “Patient’s Rights.” In fact, the higher the child’s self-assessment
DAS score, the less likely he was going to allow the staff to relay
relevant medical information to his parent. This conflict between
parent and child with regard to extension of life is well known
(37, 38). Schafer (39) reported that the basis is often related to the
desire of the child for continuing life, whereas the parent tends
to give their true feelings. There was a non-significant tendency
for child with higher interpersonal relation to assess correctly his
parent’s death anxiety state.
No correlation was found with religiosity, gender, and educa-
tion on DAS score. Many studies in the literature have reported a
bidirectional effect of religion on death anxiety, some protective
(11, 12, 14, 15), and others the opposite (16, 17). Florian and
Kravetz (40) felt that Judaism increased death anxiety, while oth-
ers reported that Christianity decreases death anxiety (40). In the
study, religiosity was examined on multiple levels: self-definition,
belief in a Superior Being, and religious behavior. No evidence
of religiosity effect on any of the DAS scores was found. Gender
played no role in the DAS score, as was also reported in the
literature (20, 24).
Elderly present with less death anxiety than their children;
however, the study’s uniqueness was that it proved that children
were unable to assess the absence of death anxiety in their own
parents and actually tended to extrapolate their own anxiety
about death onto their parents. This explains why children deny
the rights of their parent to receive information from the medical
staff, in contradiction to the patient’s rights.
In a related vein, it may also be that as one grows older,
death becomes more of an expected or normative event, and
normative or typical events are less stressful and easier to cope
with (41).
The other side of the story is that the clinical staff may have
their own problems in relating to death accompanied by death
anxiety. In a study by Peck (42), social workers with higher
death anxiety were less likely to disclose information about
advance directives with patients. Viswanathan (43) reported
that physicians preferred to notify next of kin by telephone
after a loved one’s unexpected death and was related to the
physician’s own level of death anxiety. Doctors with greater
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AUTHOR CONTRIBUTIONS
The author confirms being the sole contributor of this work and
approved it for publication.
FUNDING
No funding was received to support this submission.
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5 February 2017 | Volume 4 | Article 11